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1. How are the lymphadenopathies classified?
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Correct answer:
(1) Localized.
(a) Infective:
(i) acute, e.g. a cervical lymphadenopathy secondary to tonsillitis;
(ii) chronic, e.g. tuberculous nodes of neck.
(b) Neoplastic: due to secondary spread of tumour.
(2) Generalized.
(a) Infective:
(i) acute, e.g. glandular fever (mononucleosis), septicaemia;
(ii) chronic, e.g. human immunodeficiency virus, secondary syphilis.
(b) The reticuloses: Hodgkin's disease, non-Hodgkin's lymphoma, chronic lymphocytic leukaemia.
(c) Sarcoidosis.
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2. What are the causes of localized lymphadenopathy?
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Correct answer:
(1) Infective:
(a) acute, e.g. a cervical lymphadenopathy secondary to tonsillitis;
(b) chronic, e.g. tuberculous nodes of neck.
(2) Neoplastic: due to secondary spread of tumour.
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3. What are the causes of generalized lymphadenopathy?
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Correct answer:
(1) Infective:
(a) acute, e.g. glandular fever (mononucleosis), septicaemia;
(b) chronic, e.g. human immunodeficiency virus, secondary syphilis.
(2) The reticuloses: Hodgkin’s disease, non-Hodgkin’s lymphoma, chronic lymphocytic leukaemia.
(3) Sarcoidosis.
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4. How must you examine a patient with a lymph node enlargement?
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Correct answer:
The clinical examination of any patient with a lymph node enlargement is incomplete unless the following three requirements have been fulfilled. (1) The area drained by the involved lymph nodes has been searched for possible primary source of infection or malignant disease. There are four important points to remember. (a) Cervical lymphadenopathy. In addition to examining the skin of the head and neck, the inside of the oropharynx together with the larynx should be examined for chronic sepsis or malignant disease. (b) Inguinal lymphadenopathy. If a patient has an enlarged lymph node in the groin, the skin of the leg, buttock and lower abdominal wall below the level of the umbilicus must be scrutinized, together with the external genitalia and anal canal. (c) Testicular tumours drain along their lymphatics, which pass with the testicular vessels to the para-aortic lymph nodes, and not the inguinal lymph nodes. (d) Virchow’s node is a prominent node in the left supraclavicular fossa arising from malignant disease below the diaphragm, e.g. gastric carcinoma, with secondaries ascending the thoracic duct to drain into the left subclavian vain. A supraclavicular node may also signify spread from intrathoracic, testicular or breast tumours. (2) The other lymph node areas are examined, as enlarged lymph nodes elsewhere would suggest a generalized lymphadenopathy. (3) The liver and spleen are carefully palpated; their enlargement will suggest a reticulosis, sarcoid or glandular fever.
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5. To which lymph nodes does the testicular lymph drain?
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Correct answer:
It drains to the para-aortic lymph nodes. It does not drain to the inguinal lymph nodes.
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6. If you examined a patient with a generalized lymphadenopathy, what would your differential diagnoses be?
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Correct answer:
Reticulosis, sarcoid or glandular fever.
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7. Which special investigations should you use to investigate lymphadenopathy?
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Correct answer:
In many instances the cause of the lymphadenopathy will by now have become obvious. The following investigations may be required, in order to further elucidate the diagnosis. (1) Examination of a blood film may clinch the diagnosis of glandular fever or leukaemia. (2) Chest X-ray may show evidence of enlarged mediastinal nodes or may reveal a primary occult tumour of the lung, which is the source of disseminated deposits. (3) Serological tests: a human immunodeficiency virus antibody test is performed if infection is suspected; syphilis may be confirmed by specific treponemal antigen tests. (4) Lymph node biopsy: ultrasound-guided needle-core biopsy, or surgical removal of one of the lymph nodes, may be necessary for definite histological proof of the diagnosis. This is particularly so in Hodgkin’s disease and non-Hodgkin’s lymphoma. (5) X-ray of cervical nodes: enlarged painless cervical lymph nodes may be X-rayed; tuberculous nodes often show typical spotty calcification.
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8. Why might a lymph node biopsy be needed in the case of lymphadenopathy?
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Correct answer:
This may be needed for definite histological proof of the diagnosis. This is particularly so in the case of Hodgkin’s and non-Hodgkin’s lymphoma.
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9. What are the pathological features of tuberculous lymph nodes?
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Correct answer:
They often show typical spotty calcification.
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10. What is the general cause of lymphoedema?
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Correct answer:
Lymphoedema results from the obstruction of lymphatic flow, owing to congenital abnormalities of the lymphatics, their obliteration by disease or their operative removal. It is characterized by an excessive accumulation of interstitial fluid. The causes of lymphoedema may be divided into congenital and acquired.
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11. How many types of inherited lymphoedema exist?
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Correct answer:
There are two.
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12. What is the inheritance of inherited lymphoedema?
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Correct answer:
Autosomal dominant.
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13. In which sex is inherited lymphoedema most common?
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Correct answer:
More common in women.
